A Stitch in Time Saves Nine: Intervention Strategies for the Remediation of Competency

Child Adolesc Psychiatric Clin N Am

16 (2007) 249–264

A Stitch in Time Saves Nine:Intervention Strategies for theRemediation of Competency

Dorothy Stubbe, MDa,*, Ellen Heyneman, MDb,Saundra Stock, MDc

aYale University Child Study Center, Yale-New Haven Hospital Children’s Psychiatric

Inpatient Service, 230 South Frontage Road, New Haven, CT 06520, USAbDepartment of Psychiatry, University of California, San Diego, 3020 Children’s Way,

San Diego, CA 92123, USAcDepartment of Psychiatry and Behavioral Medicine, University of South Florida,

3515 East Fletcher Avenue, Tampa, FL 33613, USA

The art and science of training competent practitioners

As with all of medicine, training and education in child and adolescentpsychiatry are both art and science. A good training director serves as theconductor for the symphonydtransmitting a serious and passionate com-mitment to the highest standards of comprehensive care for children, adoles-cents and families, a dedication to residents’ personal and professionalgrowth, and a vision of the field, where it is and where it needs to go. Ineach institution, the instrumentation and symphonic music varies, but thebasic principles apply. Excellence in training requires coordinated andwell-constructed training experiences that adhere to all training require-ments within multiple systems (eg, medical school, hospital, clinics), are syn-chronized with the goals and structure of the broader administration (eg,dean, hospital administration, chair of department of psychiatry, divisionchair, directors of residency training), and are harmonized with theresources and needs of the division and department [1].

The enormous personal investment required of each resident to train andthe institutional and national investment in each physician provide a crucialimpetus to ensure that every resident competently completes training. Thelarge number of underserved children and families in need of child and

* Corresponding author.

E-mail address: [email protected] (D. Stubbe).

1056-4993/07/$ - see front matter � 2006 Elsevier Inc. All rights reserved.

doi:10.1016/j.chc.2006.07.009 childpsych.theclinics.com

mailto:[email protected]

250 STUBBE et al

adolescent psychiatric care provides an added incentive to train competentchild and adolescent psychiatrists to enter the workforce [2,3].

Each resident brings to the educational and training endeavor a uniqueset of personal assets and weaknesses. Some students easily master the cog-nitive and interpersonal challenges of training. Others may excel in the cog-nitive skills of didactics and struggle with the complex interpersonal andsystems-based challenges of working in clinical settings. Residents mayhave ongoing difficulties passing the standardized cognitive examinationsyet demonstrate superior and seemingly effortless skill in patient care andmultidisciplinary collaboration.

In an effort to ensure that all medical practitioners have mastered thebasic critical skills in six content areas determined to be essential to medicalpractice, the Accreditation Council for Graduate Medical Education(ACGME) identified six core areas in which a resident is required to obtaincompetence [4]. Programs must define the specific knowledge, skills, and at-titudes required for competence in each of the six core competencies andprovide educational experiences as needed in order for residents to demon-strate competence [5,6]. Elsewhere in this issue, Dingle and Beresin providea comprehensive discussion of competency training in child and adolescentpsychiatry [7]. Table 1 gives a summary of the core competencies in graduatemedical education.

Training programs must document training experiences and residentachievement of the six core competencies. Supervisors assist residents with

Table 1

Core competencies in residency training

Competency Definition

Patient care Compassionate, appropriate, and effective treatment

of patients that serves to promote health and

recovery

Medical knowledge Established and evolving biomedical, clinical, and

cognate sciences and the application of this

knowledge to patient care

Practice-based learning

and improvement

Investigation and evaluation of care for patients, the

appraisal and assimilation of scientific evidence,

and accessing of the evidence base for treatments

to improve patient care

Interpersonal and

communication skills

Effective exchange of information and collaboration

with patients, their families, and other allied health

professionals

Professionalism Commitment to carrying out professional

responsibilities, adherence to ethical principles,

and sensitivity to patients of diverse backgrounds

Systems-based practice Actions that demonstrate an awareness of and

responsiveness to the larger context and system of

health care and the ability to call effectively on

other resources in the system to provide optimal

health care for patients

251INTERVENTION FOR REMEDIATION OF COMPETENCY

areas in which they are weak, and areas of strength are acknowledged. Sit-uations in which the normal course of training is insufficient for an individ-ual resident to master the knowledge, skills, and attitudinal challenges of thetraining program must be anticipated, however. In those instances, extra as-sistance and an individualized plan of attaining competencedremediationof competencydare required.

Surprisingly little has been written about the remediation of competency inmedical education. Residents must meet competency criteria in knowledge,skills, and attitude for each of the competencies. Failure to meet the compe-tency criteria in knowledge or skills can be described as a ‘‘deficiency’’ thatmust be made up, for example, through access to a missed learning opportu-nity or repetition of previously offeredmaterial [8–11]. In contrast, the ‘‘reme-diation’’ of attitudes is amore difficult definition, which suggests that a changeis required in a resident’s viewpoint or even personality style [12]. Health im-pairments caused by physical, psychiatric, or substance abuse problems arespecial challenges to remediation, and federal and state guidelines must befollowed regarding the impaired physician and the safety of the public.

Remediation of competence is embedded within the overall philosophy oflifelong learning and improvement. At the start of any educational or train-ing endeavor, the novice does not yet possess the knowledge, skills, andattitudes required for competence. Remediation is the act of identifyingareas that are not yet performed competently and addressing them. Learnerswho are not making the progress expected of residents at their level of train-ing require remediation to ensure that the skill level is consistent with theexpertise needed to perform the tasks with competence.

Competency evaluation and monitoring in residency training

‘‘A stitch in time saves nine.’’ This proverb is particularly relevant to theresident remediation process. Prevention of resident difficulties is multi-determined and begins with a carefully crafted interview and selection pro-cess to increase the probability of admitting residents who will adapt and besuccessful in the program. Unfortunately, selection criteria for residenciestend to be poorly correlated with predictions of which medical studentsmay excel once they are in the residency [13,14]. Child and adolescent psy-chiatry training directors usually have the added advantage of possessing in-formation about resident performance within the psychiatry residencyprogram, which would be expected to correlate more highly with clinicalperformance. Several variables may obscure this correlation, however. First,letters of recommendation are often hard to ‘‘read between the lines’’ andmay be glowing for even marginal residents. The shortage of child and ad-olescent psychiatry applicants may necessitate less stringent acceptance cri-teria at times. Evidence of the resident’s dedication and motivation anda clear love of the work indicate that a resident will do well and respond pos-itively to advice and assistance, if needed.

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The competency training process includes the following crucial steps:

� Completing written competency goals and objectives for each rotation� Using assessmentmeasures of competency that are fair and usingmultipleevaluators (360� evaluations), including various formats (portfolio)� Making, implementing, and monitoring a plan for remediation ifcompetence is not attained

The training and evaluation process should be as transparent as possible[15]. Clear expectations, open and frequent communication with residentsand their supervisors, and regular and ongoing feedback about areas ofstrength and areas of need do a great deal to prevent serious disciplinaryproblems. Experienced training directors have learned that setting clearexpectations and reinforcing them early in training sets a professional pat-tern and standard of practice that may be maintained. Allowing tardinessor inconsiderate or low-level unprofessional behavior to go unnoticed canpropagate bad habits quickly in an entire residency class [16].

Productive feedback and the art of giving bad news

Competency-based training, assessment, and remediation use a skills-attainment model rather than an apprentice model of training. Formany faculty and supervisors, this method of teaching and supervisionmay be new or foreign, and faculty require a great deal of education toensure that supervision is optimally interactive, with ongoing constructivefeedback, monitoring, and engagement in the difficult task of gaining theskills needed for superior practice.

Except for the rare circumstance in which a trainee has such an egregiousviolation of ethics and practice that termination is required, residents shouldreceive constructive feedback on strengths and relative weaknesses in theirskill set and be engaged and motivated for self-improvement on an ongoingbasis. From this theoretical stance, training and supervisionmay be conceptu-alized as ongoing remediationdor remediation may be conceptualized as on-going improvement of medical practice. Remediation is not discipline. Onlywhen a resident does notmeet required expectations for improvement of prac-tice should the process move forward into a more disciplinary procedure.

The supervisory process, when done in a respectful and nonjudgmentalmanner, allows for the open discussion of areas in which a resident maybe struggling. Giving this feedback early and often and addressing concern-ing behavior or negative test scores promptly is helpful and frequently wel-comed by residents. Hearing from the training director that there isa completely unexpected negative review at the end of a rotation tends todemoralize a resident, breed resentment, and increase anxiety [1].

Faculty seminars on providing constructive supervision may be helpful inassuring greater consistency in the supervisory process. The art and scienceof supervision are rarely taught to trainees, so after graduation when a junior


faculty member is asked to supervise, he or she may lack the skill set. Super-visors frequently emulate individuals who supervised them. As the trainingendeavor becomes more complex, the effectiveness of supervision becomesmore important. Resources are available to assist faculty in the process ofeffective supervision [17,18].

The steps in the training and evaluation process include

Engaging faculty and residents in the process of competency-based trainingProviding open communication and supervision about strengths and

weaknesses on an ongoing basisHaving a comprehensive evaluation system that allows residents to under-

stand their areas of strength and weakness and identify any problemareas early (360� evaluations and a training portfolio are recommended)

Ensuring that the training program has a training atmosphere thatpromotes professionalism and does not tolerate exploitation ofresidents or unprofessional behavior of any faculty or staff

Implementing a transparent, fair, and uniformly applied process toaddress lack of competence or unprofessional behavior

Remediation of competency

Remediation versus discipline

A remediation process is not disciplinary. It is a written plan to assista resident for whom areas of deficiency have been identified. Successful re-mediation avoids disciplinary interventions. It requires devotion to the res-ident and the dedication of departmental resources to the process to help thestruggling resident become successful.

Within a training program, there are multiple levels of intervention thatinformallydor formallydaddress performance problems. It must be madeclear as to whether a remediation process will enter into the formal recordof the resident. It also is essential to articulate whether successful remedia-tion will result in a recording of performance problems in a resident’spermanent file. Some programs have remediation strategies that expungefrom the resident’s permanent record any perceived deficiencies that arefully remedied, a so-called ‘‘pencil probation.’’

The training director also must comply with the policies and proceduresof the graduate medical education office of the institution in which the train-ing program resides. Regulations vary from one institution to another, so itis essential to be aware of regulations at the local site. The training directormust clarify when he or she must correspond, formally or informally, re-garding performance problems of a resident with the graduate medical edu-cation office and with the chair of the department.

If a trainee displays deficiencies in competence that are severe, posea danger to the public, or have not been modified by a concerted and

254 STUBBE et al

comprehensive remediation plan, the remediation process may need to enterinto a disciplinary phase. Each institution has a ‘‘due process’’ procedure inplace for trainees, and the program director should be familiar with the pro-cess and ensure that all residents are informed.

Residents are interested in what information about their performance willbe conveyed to external agencies. It must be specified to the resident and un-derstood by the training director as to what information about the remedi-ation process ultimately is included in a resident’s permanent file or noted insubsequent requests for information about a resident’s performance that arereceived after completion of training [19].

Identification of the resident in need of remediation

Identifying, with as much specificity as possible, the knowledge, skills,and attitudes of a resident that require remediation is the first step in solvingthe difficulty. To do this, clear and objective data are required about residentperformance. Effective training for weaker residents relies on faculty beingcomfortable identifying a trainee’s areas of weakness, being willing to dis-cuss this with the resident, and clearly documenting the resident’s areas ofdifficulties and progress in addressing them.

It is all too common for training directors to receive written evaluationsindicating that a resident is functioning at the expected level despite verbalreports indicating the resident is struggling. Dudek and colleagues [20]looked at supervisors in medicine and surgery departments to assess theirperspective on impediments to giving failing marks to medical students orresidents. They found that the supervisors felt confident in their ability torecognize trainees with problems but did not know what specific behaviorsto document. Some supervisors also felt that there was no point to failinga trainee because they either anticipated an appeal of their evaluation orfelt that no intervention would occur to help the trainee improve. Some fac-ulty felt reluctant to be the first person to identify below-expected perfor-mance for a trainee and admitted to being more willing to reflect failurein their evaluation if other supervisors shared their concerns. Having facultyget together as a group on a regular basis to discuss all of the residents’ per-formance may help faculty feel more comfortable documenting their ownassessment of an individual resident. Clearly, addressing expectationsregarding documentation and potential outcomes for below average perfor-mance with the faculty is important.

Process and monitoring of a remediation plan

Once you have identified and clearly documented the area of weaknessfor a resident, a specific remediation plan should be created. In a recentarticle, Boiselle and Siewert [21] recommend that the following questionsbe addressed when devising a plan of remediation:


1. What is the nature of the problem? Is it knowledge, skills, or attitude/behaviors?

2. What is the resident’s perception of the issue?3. What is the faculty member’s perception of the issue?4. Are there other contributing factors (eg, health problems or relationship

problems)? For instance, according to Friedman [22], 30% of residentssuffer with significant depression and 40% have marital or relationshipdifficulties during their training.

5. What is the potential impact of the problem? Does it impact theresident’s well-being? Does it impact patient care? Does it affect otherson the team?

The training director is responsible for meeting with the resident anddiscussing the problem. It is important to foster and promote the corephilosophydthat the goal of remediation is to provide a benefit for thetrainee, not to serve as a punishment.

Understandably, residents are often defensive when first approachedabout remediation, and care should be taken to discuss the expectedoutcomes in a positive light of fostering professional development andgrowth. A remediation plan should be crafted to target the specific defi-ciencies for the resident. For example, cognitive deficits may be addressedthrough a structured review of core content. Difficulties with interpersonaland communication skills or professionalism require identification ofspecific measurable expectations, clear role definition, and regular meetingsscheduled with a faculty mentor.

Engaging a resident in the process of improvement of practice is one ofthe key challenges facing a training director. Some helpful techniques for en-gaging a resident in the remediation process are as follows:

Meeting regularly with each resident at times other than evaluation feed-back to discuss issues of training. Review strengths and areas of ongo-ing improvement in the resident’s professional training as a matter ofcourse. This atmosphere of reflecting upon performance, as well asthe caring and objective discussion about strengths and weaknesses,sets the stage for frank discussions if there is a need for remediation.

Having as much objective data as possible. Generalities and nonspecificcriticism of performance elicit defensiveness (eg, ‘‘The staff says thatyou are disrespectful to them’’). Specificity allows for a more produc-tive conversation (eg, ‘‘When you told the nurse that she should beable to handle that situation without calling you, she felt that youwere not treating her in a respectful manner’’).

Referring to training goals and objectives (knowledge, skills and atti-tudes) of the rotation and overall training program to help baseresident performance in the context of reaching these goals duringtraining. The goals can be helpful in clarifying the aspects of trainingthat have not yet been achieved and aspects that have.

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Asking the resident to help you formulate the specifics of a remediationplan. The resident who can help craft the solution is an engagedresident.

The remediation plan should document the nature and extent of theproblem, discussions between the training director and the resident, theplan for remediation, the time interval in which the remediation is to occur,how the remediation will be evaluated during this time period, and theperson who will conduct the evaluation [16]. Typically, the frequency ofevaluation and feedback to the resident is increased during the period ofremediation. Common remediation methods include meeting with facultyadvisors, assigned core content reviews, change in rotation schedules, video-taping patient interactions, modified clinic schedules, and extended training.In some circumstances, referrals for formal monitoring, counseling, or psy-chiatric assessment are warranted in addition to the formal education plan.The specific remediation plan should be put in writing and signed by thetraining director and the resident, including any change in status thataccompanies the remediation (ie, formal warnings or placing the residenton probation).

The training director should be vigilant about the approach with a res-ident and how this fits with the overarching institutional policies regardingdue process and resident expectations. Any time a remediation plan isbeing developed, it is wise to involve the graduate medical educationoffice. It may be prudent to have the graduate medical education officereview the resident’s file regarding the documentation of the problem, es-pecially if the resident’s status is affected or if the program wants to con-sider nonrenewal of the resident for the following year. The graduatemedical education office also may want the institution’s legal consultantsto review the file. The training director must know if there will be institu-tional support for recommendations coming from the faculty of theirprogram. Clear and frequent documentation is the key to effective reme-diation and disciplinary procedure. Many training directors are concernedabout potential liability of attesting to the competency of a resident, a re-quirement for the resident to graduate, for whom they had concerns. Thelegal implications of failing to terminate a resident whom the training di-rector and institution deemed substandard in his or her clinical perfor-mance have yet to be determined.

Remediation of attitudes

Remediation of attitude problems, such as deficits in professionalism andinterpersonal and communication skills, presents a particularly difficult butimportant task for the residency training director. Residents’ attitudes maybe difficult to assess in an objective manner and are far less straightforwardto remediate than deficits in resident knowledge or skills. Attitudes withinthe core competencies include various categories, such as assuming


responsibility for active and continuous learning, demonstrating flexibility byrespecting others, working collaboratively and welcoming diverse opinions,placing the needs of the patient ahead of one’s own needs, behaving ethically,and being willing to self-observe and confront personal biases and emotions.The evaluation of these attitudes is often subjective, which may lead to mis-understanding and conflict between the resident and the training director.

Professionalism is a complex competency that has been viewed as partic-ularly important yet difficult to assess and remediate. Studies have suggestedthat attitude problems and unprofessional behavior in medical school havebeen associated with disciplinary action by state licensing board decadeslater. Three domains of unprofessional behavior that were related to laterdisciplinary outcome included poor reliability and responsibility, lack ofself-improvement and adaptability, and poor initiative and motivation[23,24]. Medical students who displayed unprofessional behavior were threetimes more likely to be disciplined later by a medical board [23,25]. Trainingdirectors should screen applicants carefully for evidence of attitude prob-lems or unprofessional behavior during medical school or other residenciesto reduce the likelihood of future problems with unprofessional behavior.Once a resident is hired, however, it is the training director’s responsibilityto remediate attitudes and unprofessional behavior when observed. Canattitudes be taught, and how should these behaviors be addressed?

There has been considerable recent interest in developing professionalismcurricula within various medical schools [26]. These curricula have empha-sized the importance of professional responsibility, competence and self-improvement, respect for others and professional relationships, honesty,and social responsibility. The importance of these principles has been incor-porated into medical student courses and clerkships throughout the 4 yearsof medical school. Several medical schools have emphasized use of a profes-sionalism portfolio to document examples of professionalism. This portfoliomay include the use of self-reflection exercises or vignettes, patient testimo-nials, faculty recommendations, ancillary staff observations, and peerratings similar to the 360� evaluations used by residency programs. The pro-fessionalism portfolio has been used by the dean of student affairs incomposing letters of recommendation for residency application and maybe used by residency training directors as one means of documenting growthin professionalism. The professionalism portfolio sends a message that pro-fessionalism to the community is an important value that must be addressedas part of the education of physicians-in-training.

Vignettes that describe unprofessional behaviors also may be used asa tool to educate residents about professionalism. Vignettes may increaseawareness about standards of professional behavior and facilitate discussionin the training program about appropriate standards of behavior and theimportance of professionalism. Participants, including residents and faculty,may be asked to rate the severity of unprofessional behaviors that aredescribed in the vignette.

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Once attitudinal problems have been observed, careful documentation ofdeficiencies is an important first step in the process of remediation. Specificdeficits, such as unmet professional responsibility, lack of effort towardself-improvement, poor adaptability, disrespect for others, dishonesty, ormisconduct, must be documented carefully to begin the process. The useof 360� evaluations can be highly useful in assessing professionalism orbehavior problems. The best approach is direct observation by multipleobservers, including faculty members, peers, patients, and staff. Residentsalso may be asked to make self-assessments about attitudes and behaviors.Regularly scheduled faculty discussions also can help identify important res-ident performance issues that may not appear on written evaluations. It isimportant to elicit the faculty’s and resident’s perception of the issue anddetermine whether other contributing personal issues (eg, depression, anxi-ety, substance use, personal or family issues) are contributing to the resi-dent’s performance problems [21,27]. Occasionally, larger system issueswithin the residency program may be contributing. The development ofan appropriate plan takes into consideration the potential impact of theproblem on patient care, other residents, and faculty.

In some instances, the training director may be concerned about a single,discrete incident or behavior, such as disrespectful behavior toward a singleindividual or failure to prepare for a particular educational activity. In thesecases, the training director can meet with the resident to discuss the situationand perceived problem to constructively enhance the resident’s professionalgrowth and prevent recurrence of this attitude or behavior.

The more challenging situations involve chronic, pervasive problems withinappropriate attitudes that result in a pattern of unacceptable behavior bya resident. This category may include the resident who is chronically late forappointments, seminars, or meetings or the resident who repeatedly fails torespond to pages while on call. Once the problem areas are identified withthe resident, specific expected behaviors should be identified (eg, arrive ontime for appointments, answer all pages within 5 minutes) and remediationgoals established to address these behaviors. Residents with chronic, perva-sive difficulties may become defensive or highly resistant to developing in-sight into the significance of their problematic behaviors, which maymake remediation particularly difficult.

It is frequently useful to appoint a faculty mentor who can work with res-idents on attitudinal issues. The attitudinal mentor may be useful to monitorand provide feedback on the identified deficits. It is essential to involve res-idents in developing the intervention plan and selecting the mentor to en-hance the likelihood that the intervention is perceived positively byresidents rather than as a punitive situation that is met with opposition.The mentor should be non-authoritarian, direct, and clear [19]. The roleof the mentor also must be specified clearly. The mentor is not an individualpsychotherapist. Rather, the mentor is an advisor/advocate. The mentorserves the role of confidante and counselordgiving concrete advice,


providing clear feedback, and closely monitoring resident progress towardprofessionalism goals. In cases in which personality disorder, chronic stress,or other personal issues are contributing to the problem, the addition of psy-chotherapy to the remediation recommendations should be considered.

The faculty in residency training programs in child and adolescent psy-chiatry are generally psychiatrists. This factor has the advantage of increas-ing awareness about the complexities of interpersonal and stress-relatedbehaviors and issues of transference and countertransference in supervision.The risk of diagnosing psychiatric maladies in residents who have perfor-mance issues is ever-present, however. Residency training directors mustbe vigilant during residency review meetings that residents who are notperforming up to expectations not be merely labeled with a psychiatricdisorderdAxis I or II. It is the role of the training director to maintain afocus on performance and constructive plans to help the resident change in-appropriate behavior while simultaneously considering the potential thata treatable disorder may be impairing the physician’s functioning.

Problems with attitude and resident behavior may at times suggest seri-ous underlying psychopathology or substance abuse. Residents whose abil-ity to practice medicine is affected by substance abuse or medical orpsychiatric illness pose a significant challenge to the residency training direc-tor. The duty to protect the public requires identification and early interven-tion with residents whose ability to practice medicine safely is impaired. Theconcern should be discussed directly with the resident and a plan of actiondetermined. This plan may include a mandated evaluation and mandatedtreatment. Issues of monitoring compliance and effectiveness of treatmentshould be discussed with the graduate medical education and legal officesof the institution. Residents must be informed about the limits of confiden-tiality with the professional providing treatment and the nature of informa-tion required by the program. Most often, a written note about issues ofimpairment, compliance with treatment recommendations, and progress isrequired, as is a medical note indicating clearance to return to work. Resi-dents require clear written criteria for returning to the program or endingtreatment and may require ongoing monitoring and periodic follow-upwith a professional to ensure continued competence to practice safely.

When remediation becomes discipline: due process procedures

If a resident demonstrates deficiencies in competence that are severe, maypose a danger to the public, or have not been modified by a comprehensiveremediation plan, the remediation process may enter the disciplinary phase.Each institution must have written due process procedures that outline theprocess clearly for the resident and training director. The graduate medicaleducation and legal office for the institution should be involved wheneverthe remediation process enters this phase. The residency training directoris responsible for ensuring competent graduating physicians, and faculty

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should not fear legal action because of a negative evaluation of a resident’sperformance. The courts have strongly supported the decision of academicfaculty in dismissing residents unless evidence of discrimination or otherwrongdoing by the faculty exists. Residents are viewed as clinicians/facultyrather than as students by the courts as far as disciplinary action is con-cerned. The court has supported disciplinary actions, including dismissalof residents, in the interest of public safety.

Steps in a remediation process include

� Providing performance evaluations� Supplying written warnings� Providing prescriptive/remedial procedures

One formal level of action is whether a resident’s annual contractwill be renewed. Graduate medical education offices have obligationsthat require timely notice of non-reappointment, typically 6 months inadvance of the point of reappointment. In some instances, a decisionto not renew a contract may be reconsidered upon successful addressingof areas of performance difficulty. This decision must be articulated inadvance.

Other levels of the management of performance problems include theformal placement of a resident on probation. Terms of that probationmust be articulated specifically. Typically, a resident is not placed on pro-bation until lesser measures have been used and have not been successful.In the case of probation, grievance procedures are available to residentsthat they may pursue if they feel that placement on probation was an un-fair judgment. Residents must be aware of these grievance procedures.When a resident is placed on probation, that finding is recorded in hisor her permanent file.

In rare instances, a resident may be terminated for cause. In this case, in-forming grievance procedures is also absolutely essential. Types of disciplin-ary action include

� Probation, which involves strictly written expectations for which thetrainee is closely monitored, with the explicit plan for termination ifthe expectations are not met� Retention, extending the training time to remediate areas of deficiency� Nonrenewal of appointment, which provides advanced warning anda planned nonrenewal of the training appointment before graduation� Terminationddismissal from the programdusually for egregious or on-going professional violations.� Not certifying for board qualification. Some training directors havegraduated residents but not attested to competency in the letter sentto the board for eligibility for specialty certification. Most programsand procedures for attestation of competency currently forbid thisoption.


Special issues

Departmental resources

In some instances residents with performance problems may not receivecredit for portions of their training. Remediation may require extension oftraining. Mechanisms for funding extended training must be identified. Iden-tification may be problematic because training budgets typically anticipatethe numbers of residents to be funded. There often are problems securing ad-ditional stipends, particularly if the need is a result of unsatisfactory perfor-mance. The obligation of the training institution to remediate must beconveyed clearly to the division head and chair, so that a contingency planmay be made for this potential occurrence. Using rotations that provide sti-pend support and finding community agencies that may fund a resident sti-pend while faculty (regular and voluntary) provide intensive supervisionand monitoring are potential funding sources of extended resident training.Engaging the graduate medical education office, chair of the department,and the division director early in the process of remediation is essential to theirengagement in the serious and essential task of training competent physicians.

The training environment

Although remediation of competence assumes that the nature of the diffi-culty lies within the resident, several training variables may confound this as-sumption. A residency training program that is insensitive to issues ofculture, gender, and level of stress in the program erodes morale and leavesresidents at risk for poor performance. Playing favorites by faculty towardcertain residents may encourage acting out or other noncollaborative behav-iors in an effort to be recognized by persons in charge. Some suboptimal con-ditions violate training requirements (the 80-hour workweek and need tomonitor resident stress), and others violate laws (discrimination or harass-ment based on race, culture, or gender). It is the training director’s job to pro-vide a training atmosphere that is respectful and professional and monitorsfor appropriate professional boundaries between faculty and residents.

Residentsmust be able tomanage appropriate amounts of stress in the clin-ical environment, because the work with disturbed children and families canbe stressful. Excessive stress within the program must be identified and reme-died, however. Trends in resident performance shouldbemonitored. If a singleresident is displaying difficulties, the intervention targets assistance and reme-diation of the difficulty experienced by that resident. If several residents dem-onstrate suboptimal performance, however, training program variables maybe contributing. The training director should take feedback about theprogram seriously, ensure that residents have a voice in curriculumassessmentand modifications, and provide ongoing monitoring of the rotations, the cur-riculum, and the teaching and supervisory faculty to ensure that the programprovides an environment that optimizes learning and skill acquisition.

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Programs require remediation if competent training is not provided. ‘‘Be-ginning July, 2006, the accreditation focus will be on evidence that programsare making data-driven improvements, using not only resident performancedata, but also external measures’’ [28]. Increasingly, residency training pro-grams must demonstrate that residents are meeting quality criteria in termsof various measures (eg, psychiatry resident-in-training examination,PRITE and Child PRITE, National Board of Psychiatry and Neurology ex-amination scores, in-training clinical assessments) to maintain accreditation.The success of residents in the program directly impacts accreditation status.

Components of successful remediation: the next steps

Child and adolescent psychiatry educators strive to perfect the art andscience of training competent to superior physicians who then become thenext generation of clinicians, scientists, and educators. Training directorsare, almost by definition, role models and mentors in addition to clinicians,educators, and sometimes researchers.

There has been a somewhat arbitrary delineation of clinician versusresearcher. Most training directors fit in the ‘‘clinician educator’’ trackof academic departments. This is appropriate, because the task of curricu-lum development and medical and postgraduate training is time consumingand a position that requires skill and substantial expertise in administra-tion and teaching. Training directors tend to turn over rapidly (approxi-mately two thirds are training directors for less than 5 years), whereasthe career educator (approximately one third of child and adolescent psy-chiatry training directors) is an immensely satisfying academic niche formany [29].

The mission of medical educators in all fields is to perfect the science andthe art of training competent physicians and the next generation of leaders.To do this, outcomes research regarding effective training and supervisiontechniques and curricula, the optimal educational environment, assessment,and remediation of competency is needed. The ACGME has provided theimpetus, but it is incumbent upon training directors to continue to providethe primary leadership for the field of training. The areas that are ripe forresearch and development include effective curricula, effective evaluationand remediation of competency, and leadership skill development. As med-icine becomes more complex, so does the task of training physicians. Jointmonitoring and outcomes research of the training enterprise are the schol-arly and academic missions of the present and the future.

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Documents

A Stitch in Time Saves Nine: Intervention Strategies for the Remediation of Competency